Cigarette smoking is the leading preventable cause of death in the U.S. The 2008 US Public Health Service Smoking Cessation Guideline recommends offering effective treatment that includes both medication and counseling to smokers in all health care settings, including hospitals. Nearly 4 million smokers are hospitalized each year, and hospital admission offers a teachable moment for intervention. In-hospital smoking cessation intervention is efficacious, but only if contact continues for >1 month after discharge. The challenge is to translate this efficacy from research into clinical practice by identifying an evidence-based cost-effective model that U.S. hospitals can adopt. The major barrier is sustaining contact after discharge. This project tests an innovative strategy to efficiently sustain patient contact after discharge by streamlining the delivery of post- discharge smoking interventions in order to maximize their uptake. Specific Aim: To test the effectiveness of an innovative strategy to increase hospitalized smokers' long-term tobacco abstinence rate by maximizing their use of evidence-based tobacco treatment (counseling and medication) after hospital discharge. Study Design: A multi-site randomized controlled comparative effectiveness trial will enroll 1350 adult smokers admitted to 3 acute care hospitals in Massachusetts and Pennsylvania. All subjects will receive a brief in-hospital smoking intervention and be randomly assigned at discharge to either Standard Care (referral to the MA or PA state quitline) or Extended Care, consisting of a 3-month program with 2 components: (1) Free Medication: A 30- day supply of FDA-approved medication (nicotine replacement, bupropion, or varenicline) given at hospital discharge and refillable free for a total of 90 days to facilitate medication use and adherence; (2) Interactive Voice Response (IVR) Triage to Telephone Counseling from a national quitline provider (Free & Clear). IVR is proactive. It aims to encourage medication adherence and enhance counseling efficiency by identifying smokers who need post-discharge support. Immediate transfer of a patient from automated IVR call to a live telephone counselor will facilitate a successful connection to counseling. Using a national quitline provider offers efficient scaling. Outcomes, assessed at 1, 3, and 12 months after hospital discharge, are: (1) intervention effectiveness (cotinine-validated 7-day point-prevalence tobacco abstinence rate at 12 month follow-up [1o outcome] and other measures of tobacco abstinence); (2) smoking cessation treatment utilization, and (3) cost-effectiveness (cost per quit). An exploratory analysis will examine the intervention's effect on health and health care utilization (hospital readmission and mortality in the 12 months after discharge). Policy implication: Standard Care meets current Medicare and Joint Commission National Hospital Quality Measures (NHQM) for tobacco. Extended Care meets the revised tobacco NHQM that are being reviewed for adoption. This trial of Extended Care will provide strong evidence about the proposed hospital quality measure revisions and could offer U.S. hospitals an evidence-based way to comply with them. PUBLIC HEALTH RELEVANCE: Cigarette smoking is the leading preventable cause of death in the U.S. Smoking cessation reduces risk and extends life expectancy. This project aims to identify a cost-effective strategy for delivering smoking cessation treatment to the nearly 4 million U.S. smokers who are hospitalized each year.